Association between the social vulnerability index and breast, cervical, and colorectal cancer screening rates in Rhode Island.

BACKGROUND: Cancer screening is effective in reducing the burden of breast, cervical, and colorectal cancers, but not all communities have appropriate access to these services. In this study, we aimed to identify under-resourced communities by assessing the association between the Social Vulnerability Index (SVI) with screening rates for breast, cervical, and colorectal cancers in ZIP-code tabulation areas (ZCTAs) in Rhode Island. METHODS: This study leveraged deidentified health insurance claims data from HealthFacts RI, the state's all-payer claims database, to calculate screening rates for breast, cervical, and colorectal cancers using Healthcare Effectiveness Data and Information Set measures. We used spatial autoregressive Tobit models to assess the association between the SVI, its four domains, and its 15 component variables with screening rates in 2019, accounting for spatial dependencies. RESULTS: In 2019, 73.2, 65.0, and 66.1% of eligible individuals were screened for breast, cervical, and colorectal cancer, respectively. For every 1-unit increase in the SVI, screening rates for breast and colorectal cancer were lower by 0.07% (95% CI 0.01-0.08%) and 0.08% (95% CI 0.02-0.15%), respectively. With higher scores on the SVI's socioeconomic domain, screening rates for all three types of cancers were lower. CONCLUSION: The SVI, especially its socioeconomic domain, is a useful tool for identifying areas that are under-served by current efforts to expand access to screening for breast, cervical, and colorectal cancer. These areas should be prioritized for new place-based partnerships that address barriers to screening at the individual and community level.

Assessing colposcopy competencies in medically underserved communities: a multi-center study in China.

BACKGROUND: Colposcopy plays an essential role in diagnosing cervical lesions and directing biopsy; however, there are few studies of the capabilities of colposcopists in medically underserved communities in China. This study aims to fill this gap by assessing colposcopists' competencies in medically underserved communities of China. METHODS: Colposcopists in medically underserved communities across China were considered eligible to participate. Assessments involved presenting participants with 20 cases, each consisting of several images and various indications. Participants were asked to determine transformation zone (TZ) type, colposcopic diagnoses and to decide whether biopsy was necessary. Participants are categorized according to the number of colposcopic examinations, i.e., above or below 50 per annum. RESULTS: There were 214 participants in this study. TZ determination accuracy was 0.47 (95% CI 0.45,0.49). Accuracy for colposcopic diagnosis was 0.53 (95% CI 0.51,0.55). Decision to perform biopsies was 0.73 accurate (95% CI 0.71,0.74). Participants had 0.61 (95% CI 0.59,0.64) sensitivity and a 0.80 (95% CI 0.79,0.82) specificity for detecting high-grade lesions. Colposcopists who performed more than 50 cases were more accurate than those performed fewer across all indicators, with a higher sensitivity (0.66 vs. 0.57, p = 0.001) for detecting high-grade lesions. CONCLUSIONS: In medically underserved communities of China, colposcopists appear to perform poorly at TZ identification, colposcopic diagnosis, and when deciding to biopsy. Colposcopists who undertake more than 50 colposcopies each year performed better than those who perform fewer. Therefore, colposcopic practice does improve through case exposure although there is an urgent need for further pre-professional and clinical training.

Telerheumatology Shared-Care Model: Leveraging the Expertise of an Advanced Clinician Practitioner in Arthritis Care (ACPAC)-Trained Extended Role Practitioner in Rural-Remote Ontario.

OBJECTIVE: A shortage of rheumatologists has led to gaps in inflammatory arthritis (IA) care in Canada. Amplified in rural-remote communities, the number of rheumatologists practicing rurally has not been meaningfully increased, and alternate care strategies must be adopted. In this retrospective chart review, we describe the impact of a shared-care telerheumatology model using a community-embedded Advanced Clinician Practitioner in Arthritis Care (ACPAC)-extended role practitioner (ERP) and an urban-based rheumatologist. METHODS: A rheumatologist and an ACPAC-ERP established a monthly half-day hub-and-spoke-telerheumatology clinic to care for patients with suspected IA, triaged by the ACPAC-ERP. Comprehensive initial assessments were conducted in-person by the ACPAC-ERP (spoke); investigations were completed prior to the telerheumatology visit. Subsequent collaborative visits occurred with the rheumatologist (hub) attending virtually. Retrospective analysis of demographics, time-to-key care indices, patient-reported outcomes, clinical data, and estimated travel savings was performed. RESULTS: Data from 124 patients seen between January 2013 and January 2022 were collected; 98% (n = 494/504 visits) were virtual. The average age of patients at first visit was 55.6 years, and 75.8% were female. IA/connective tissue disease (CTD) was confirmed in 65% of patients. Mean time from primary care referral to ACPAC-ERP assessment was 52.5 days, and mean time from ACPAC-ERP assessment to the telerheumatology visit was 64.5 days. An estimated 493,470 km of patient-related travel was avoided. CONCLUSION: An ACPAC-ERP (spoke) and rheumatologist (hub) telerheumatology model of care assessing and managing patients with suspected IA in rural-remote Ontario was described. This model can be leveraged to increase capacity by delivering comprehensive virtual rheumatologic care in underserved communities.

Applying data science methodologies with artificial intelligence variant reinterpretation to map and estimate genetic disorder prevalence utilizing clinical data.

Data science methodologies can be utilized to ascertain and analyze clinical genetic data that is often unstructured and rarely used outside of patient encounters. Genetic variants from all genetic testing resulting to a large pediatric healthcare system for a 5-year period were obtained and reinterpreted utilizing the previously validated Franklin© Artificial Intelligence (AI). Using PowerBI©, the data were further matched to patients in the electronic healthcare record to associate with demographic data to generate a variant data table and mapped by ZIP codes. Three thousand and sixty-five variants were identified and 98% were matched to patients with geographic data. Franklin© changed the interpretation for 24% of variants. One hundred and fifty-six clinically actionable variant reinterpretations were made. A total of 739 Mendelian genetic disorders were identified with disorder prevalence estimation. Mapping of variants demonstrated hot-spots for pathogenic genetic variation such as PEX6-associated Zellweger Spectrum Disorder. Seven patients were identified with Bardet-Biedl syndrome and seven patients with Rett syndrome amenable to newly FDA-approved therapeutics. Utilizing readily available software we developed a database and Exploratory Data Analysis (EDA) methodology enabling us to systematically reinterpret variants, estimate variant prevalence, identify conditions amenable to new treatments, and localize geographies enriched for pathogenic variants.

Hispanic individuals' cervical cancer screening disparities amidst the COVID-19 pandemic.

OBJECTIVE: To examine the impact of the COVID-19 pandemic on cervical cancer screening rates of Hispanic individuals compared to non-Hispanic White (NHW) individuals in the United States, whether a responsive surge in catch-up screenings occurred as society adapted to pandemic changes, and to investigate the sociodemographic characteristics between the study populations. METHODS: Using cross-sectional data from the All of Us Research Program, which incorporates electronic health record data and survey data from a demographically, geographically, and medically diverse participant group, we assessed the annual cervical cancer screening rates during 2019-2021 by race/ethnicity among eligible individuals ages 21-64. RESULTS: Among 116,052 unique individuals (78,829 NHW and 37,223 Hispanic), Hispanic individuals had lower annual cervical cancer screening rates than NHWI across the three years studied. They experienced a more significant decrease in screening from 2019 to 2020 (39.27 %) compared to NHWIs (21.15 %) and less of a rebound increase in the following year, 2021 (10.33 % vs 13.83 %). Hispanic individuals aged 50-64 experienced the sharpest decline in screening rates (-43.01 % from 2019 to 2020). Hispanic individuals also experienced greater adverse social conditions, including lack of insurance or employment, lower educational attainment, and lower household income. CONCLUSIONS: Hispanic individuals experienced a more significant decrease in cervical cancer screening rates with the onset of the COVID-19 pandemic compared with NHW individuals and did not experience a robust rebound in cervical cancer screening rates in 2021. As a result, the disparity in cervical cancer screening rates between NHW and Hispanic individuals considerably worsened with the COVID-19 pandemic.

How far is too far? Cancer prevention and clinical trial enrollment in geographically underserved patient populations.

Despite dedicated efforts to improve equitable access to cancer care in the United States, disparities in cancer outcomes persist, and geographically underserved patients remain at an increased risk of cancer with lower rates of survival. The critical evaluation of cancer prevention inequities and clinical trial access presents the opportunity to outline novel strategies to incrementally improve bookended access to gynecologic cancer care for geographically underserved patients. Cancer prevention strategies that can be addressed in the rural patient population mirror priorities in the Healthy People 2030 objectives and include increased identification of high risk individuals who may benefit from increased cancer screening and risk reduction, increasing the proportion of people who discuss interventions to prevent cancer, such as HPV vaccination, with their provider, and increasing the proportion of adults who complete evidence based cancer screening. Barriers to accrual to clinical trials for rural patients overlap significantly with the same barriers to obtaining health care in general. These barriers include: lack of facilities and specialized providers; lack of robust health infrastructure; inability to travel; and financial barriers. In this review, we will discuss current knowledge and opportunities to improve cancer prevention initiatives and clinical trial enrollment in geographically underserved populations with a focus on rurality.

The Use of Social Marketing in Community-Wide Physical Activity Programs: A Scoping Review.

BACKGROUND: Previous community-wide physical activity trials have been criticized for methodological limitations, lack of population-level changes, and insufficient reach among underserved communities. Social marketing is an effective technique for community-wide behavior change and can coincide with principles of community-based participatory research (CBPR). PURPOSE: A systematic scoping review of community-wide interventions (system-level) targeting physical activity and/or weight loss was conducted to (i) describe and critically discuss how social marketing strategies are implemented; (ii) identify which populations have been targeted, including underserved communities; (iii) evaluate the use of CBPR frameworks; (iv) assess retention rates; and (v) identify gaps in the literature and formulate future recommendations. METHODS: Eligible studies included those that: aimed to improve physical activity and/or weight loss on a community-wide level, used social marketing strategies, and were published between 2007 and 2022. RESULTS: Approximately 56% of the studies reported a positive impact on physical activity. All studies described social marketing details in alignment with the five principles of social marketing (product, promotion, place, price, and people). Only two studies explicitly identified CBPR as a guiding framework, but most studies used one (k = 8, 32%) or two (k = 12, 48%) community engagement strategies. Few studies included at least 50% representation of African American (k = 2) or Hispanic (k = 3) participants. CONCLUSIONS: This review highlights key gaps in the literature (e.g., lack of fully-developed CBPR frameworks, reach among underserved communities, randomized designs, use of theory), highlights examples of successful interventions, and opportunities for refining community-wide interventions using social marketing strategies.

The purpose of this study was to conduct a systematic scoping review of community-wide interventions targeting physical activity and/or weight loss to describe how social marketing strategies have been implemented, identify which populations have been targeted, evaluate the use of Community-Based Participatory Research (CBPR) frameworks, assess retention rates and identify gaps in the literature and formulate future recommendations. Over half of the studies reported a positive impact on physical activity. All studies described social marketing details in alignment with the five principles of social marketing (product, promotion, place, price, and people). Only two studies explicitly identified CBPR as a guiding framework, but most studies used one or two community engagement strategies. Few studies included at least 50% representation of African American or Hispanic participants. Many of the programs provided health information on the benefits of being active (e.g., educational lessons), behavioral strategies (e.g., walking with friends and family), or opportunities to increase walking and physical activity (e.g., community activities, walking clubs, maps for walking or biking, gardening). A number of the programs also addressed environmental facilitators for walking such as utilizing signage for stair use, accessing parks, or participating in community walking groups. Overall this review highlights key gaps in the literature (e.g., lack of fully-developed CBPR frameworks, reach among underserved communities, randomized designs, use of theory), and highlights examples of successful interventions, and opportunities for refining community-wide interventions using social marketing strategies.

Time to STEP UP: methods and findings from the development of guidance to help researchers design inclusive clinical trials.

BACKGROUND: It is important to design clinical trials to include all those who may benefit from the intervention being tested. Several frameworks have been developed to help researchers think about the barriers to inclusion of particular under-served groups when designing a trial, but there is a lack of practical guidance on how to implement these frameworks. This paper describes the ACCESS project, the findings from each phase of the project and the guidance we developed (STEP UP) on how to design more inclusive trials. METHODS: Development of the STEP UP guidance had five phases: (1) Scoping literature review, (2) 'roundtable' discussion meetings, (3) redesign of trials, (4) interviews and (5) guidance document development, with input from public contributors and the ACCESS team. RESULTS: Over 40 experts contributed to the ACCESS project-patients and the public, clinicians, NHS research staff, trialists and other academics. The scoping review identified several strategies being used to improve inclusion, mostly around recruitment settings, but there was little evaluation of these strategies. The 'roundtable' discussions identified additional strategies being used across the UK and Ireland to improve inclusion, which were grouped into: Communication, Community engagement, Recruitment sites, Patient information, Flexibility, Recruitment settings, Consent process, Monitoring, Training for researchers and Incentives. These strategies were used to redesign three existing trials by applying one of the three INCLUDE frameworks (ethnicity, socioeconomic disadvantage, impaired capacity to consent) to one trial each, to produce the key recommendations for the guidance. Issues around implementation were explored in stakeholder interviews and key facilitators were identified: funders requesting information on inclusion, having the time and funding to implement strategies, dedicated staff, flexibility in trial protocols, and considering inclusion of under-served groups at the design stages. The STEP UP guidance is freely available at http://step-up-clinical-trials.co.uk . CONCLUSION: Researchers should consider inclusivity to shape initial trial design decisions. Trial teams and funders need to ensure that trials are given both the resources and time needed to implement the STEP UP guidance and increase the opportunities to recruit a diverse population.

Randomised clinical trials compare one or more treatments to another to see which ones work best. Trials don't always include people or groups who might benefit from the results: those excluded are sometimes called 'under- served groups'. Recent work has shone a light on this and now researchers are being asked by the public, trial funders and others to design their research so that under-served groups are more able to take part.We worked on a project to find out how to make sure everyone can be part of clinical trials. We looked at published work and held five online meetings with researchers, doctors, and patients to see what was being done already, and to think of other things that could help under-served groups take part in trials. Three groups of people, including scientists, patients, doctors and other NHS workers then  used this information to redesign three older trials using some existing inclusivity frameworks to think through the barriers for under-served groups in these trials. The three groups then talked through these trials at a 2-hour meeting, suggesting changes to the original trial plan, and discussed whether the suggestions were practical and useful. From this we came up with recommendations for how to design trials so that they have fewer barriers for under-served groups.We interviewed people to find out the best way to put these things into practice and talk through any practical issues. Using all of this information: the recommendations and what came out of the interviews, the study team created some guidance ­ 'STEP UP (Strategies for Trialists to promote Equal Participation in clinical trials for Under-served Populations)' ­ for people working in trials.

Sustainable Development in Rural Underserved Communities through Improved Responsible Management of Decentralized Wastewater Infrastructure: A Focus on the Alabama Black Belt.

Despite global efforts on meeting sustainable development goals by 2030, persistent and widespread sanitation deficits in rural, underserved communities in high-income countries─including the United States (US)─challenge achieving this target. The recent US federal infrastructure funding, coupled with research efforts to explore innovative, alternative decentralized wastewater systems, are unprecedented opportunities for addressing basic sanitation gaps in these communities. Yet, understanding how to best manage these systems for sustainable operations and maintenance (O&M) is still a national need. Here, we develop an integrated management approach for achieving such sustainable systems, taking into account the utility structure, operational aspects, and possible barriers impeding effective management of decentralized wastewater infrastructure. We demonstrate this approach through a binomial logistic regression of survey responses from 114 public and private management entities (e.g., water and sewer utilities) operating in 27 states in the US, targeting the rural Alabama Black Belt wastewater issues. Our assessment introduces policy areas that support sustainable decentralized wastewater systems management and operations, including privatizing water-wastewater infrastructure systems, incentivizing/mandating the consolidation of utility management of these systems, federally funding the O&M, and developing and retaining water-wastewater workforce in rural, underserved communities. Our discussions give rise to a holistic empirical understanding of effective management of decentralized wastewater infrastructure for rural, underserved communities in the US, thereby contributing to global conversations on sustainable development.

A scoping review of costing methodologies used to assess interventions for underserved pregnant people and new parents.

BACKGROUND: Lack of evidence about the long-term economic benefits of interventions targeting underserved perinatal populations can hamper decision making regarding funding. To optimize the quality of future research, we examined what methods and costs have been used to assess the value of interventions targeting pregnant people and/or new parents who have poor access to healthcare. METHODS: We conducted a scoping review using methods described by Arksey and O'Malley. We conducted systematic searches in eight databases and web-searches for grey literature. Two researchers independently screened results to determine eligibility for inclusion. We included economic evaluations and cost analyses of interventions targeting pregnant people and/or new parents from underserved populations in twenty high income countries. We extracted and tabulated data from included publications regarding the study setting, population, intervention, study methods, types of costs included, and data sources for costs. RESULTS: Final searches were completed in May 2024. We identified 103 eligible publications describing a range of interventions, most commonly home visiting programs (n = 19), smoking cessation interventions (n = 19), prenatal care (n = 11), perinatal mental health interventions (n = 11), and substance use treatment (n = 10), serving 36 distinct underserved populations. A quarter of the publications (n = 25) reported cost analyses only, while 77 were economic evaluations. Most publications (n = 82) considered health care costs, 45 considered other societal costs, and 14 considered only program costs. Only a third (n = 36) of the 103 included studies considered long-term costs that occurred more than one year after the birth (for interventions occurring only in pregnancy) or after the end of the intervention. CONCLUSIONS: A broad range of interventions targeting pregnant people and/or new parents from underserved populations have the potential to reduce health inequities in their offspring. Economic evaluations of such interventions are often at risk of underestimating the long-term benefits of these interventions because they do not consider downstream societal costs. Our consolidated list of downstream and long-term costs from existing research can inform future economic analyses of interventions targeting poorly served pregnant people and new parents. Comprehensively quantifying the downstream and long-term benefits of such interventions is needed to inform decision making that will improve health equity.

Inequities in access to palliative and end-of-life care in the black population in Canada: a scoping review.

BACKGROUND: Improving equity and early access to palliative care for underserved populations in Canada is a priority. Little is known regarding access to palliative and end-of-life care in the Black population. METHODS: We undertook a scoping review using the framework by Arksey and O'Malley to identify knowledge, access gaps, and experiences of palliative and end-of-life care among Blacks living with life-limiting illnesses in Canada. Primary studies, discussion papers, books, and reports were considered eligible. We followed a comprehensive search strategy developed by an information scientist. Searches were performed in the following bibliographic databases: Medline, EMBASE, PsycINFO via OVID, CINAHL via EBSCOhost, Scopus and Cochrane Library via Wiley. The search strategy was derived from three main concepts: (1) Black people; (2) Canada and Canadian provinces; (3) Palliative, hospice, or end-of-life care. No publication date or language limits were applied. Titles and abstracts were screened for eligibility by one reviewer and full text by two independent reviewers. RESULTS: The search yielded 233 articles. Nineteen articles were selected for full-text review, and 7 articles met the inclusion criteria. These studies were published between 2010 and 2021, and conducted in the provinces of Ontario and Nova Scotia only. Studies used both quantitative and qualitative methods and included cancer decedents, next of kin, family caregivers and religious leaders. Sample sizes in various studies ranged from 6 - 2,606 participants. Included studies reported a general lack of understanding about palliative and end-of-life care, positive and negative experiences, and limited access to palliative and end-of-life care for Blacks, across all care settings. CONCLUSION: Findings suggest limited knowledge of palliative care and inequities in access to palliative and end-of-life care for Blacks living with life-limiting illnesses in 2 Canadian provinces. There is an urgent need for research to inform tailored and culturally acceptable strategies to improve understanding and access to palliative care and end-of-life care among Blacks in Canada.

Race-Ethnicity, Rurality, and Age in Prospective Preferences and Concerns Regarding Closed-Loop Implanted Neural Devices.

OBJECTIVE: Responsive and human-centered neurotechnology development requires attention to public perceptions, particularly among groups underserved by existing treatments. METHODS: The authors conducted a preregistered nationally representative survey (https://osf.io/ej9h2) using the NORC at the University of Chicago AmeriSpeak panel. One vignette compared an implanted neural device with surgical resection in a scenario involving epilepsy, and another compared an implanted neural device with medications in a scenario involving mood disorders. The survey also contained questions about respondents' confidence that a device would be available if needed and confidence that enough research has been conducted among people like themselves. Responses were entered into nested survey-weighted logistic regression models, including a base demographic model (to test the overall effect of demographic factors) and an adjusted model that also included socioeconomic, religious and political, and health care access predictors. RESULTS: A total of 1,047 adults responded to the survey, which oversampled Black non-Hispanic (N=214), Hispanic (N=210), and rural (N=219) Americans. In the base demographic model, older Americans were more likely to prefer an implanted device in the two scenarios, and non-Hispanic Black Americans were less likely than non-Hispanic White Americans to prefer a device; rural Americans were less confident than urban or suburban Americans in having access, and non-Hispanic Black and rural Americans were less confident that enough research has been conducted among people like themselves. In adjusted models, income was a key mediator, partially explaining the effect of age and the contrast between Black and White non-Hispanic respondents on preferences for a device in the epilepsy scenario and fully explaining the effect of rurality on confidence in access. CONCLUSIONS: Demographic differences in prospective preferences and concerns highlight the importance of including members of underserved communities in neurotechnology development.

The Care of Older People With Depression in Nigeria: Qualitative Exploration of the Experience of Lay Providers in Primary Care Settings.

OBJECTIVES: There is a large treatment gap for mental health conditions in sub-Saharan Africa where most patients who receive any care do so from lay primary health care workers (PHCW). We sought to examine the experiences of PHCW who provide care for older people with depression in Nigerian primary health care (PHC) settings. METHODS: Qualitative study design. A total of 24 PHCW participated. Using in-depth key informant interviews (KIIs), we explored the views of 15 PHCW selected from 10 rural and urban PHCs in South-Western Nigeria. An additional focus group discussion comprising nine participants was also conducted to discuss emerging themes from KIIs. Data were analysed using thematic analysis. RESULTS: Three overall themes were identified: views about depression, treatment options, and community outreach implications. Participants perceived depression in older people as being characterised by a range of mood, behavioural, and cognitive symptoms which made clinical assessments particularly challenging. Common treatment options used by PHCW included general advice and counselling, as well as frequent need to prescribe mild analgesics, vitamins and occasional sedatives in line with patients' expectations. Antidepressants were rarely used even though PHCW are authorised. While home visits are part of their expected work schedule, PHCW rarely implemented these due to non-availability of transport facilities. Mobile technology was identified as a possible way of overcoming this constraint to providing community based mental healthcare for older people. CONCLUSION: PHCWs perceived that patients' poor cognitive performance, expectations to prescribe sedatives, analgesics and vitamins, as well as non-existence of community-based services were existing barriers to providing evidenced based continued care for older people with depression in the study settings.

Enhancing recruitment of individuals living with frailty, multimorbidity and cognitive impairment to Parkinson's research: experiences from the PRIME-UK cross-sectional study.

BACKGROUND AND OBJECTIVES: People with parkinsonism who are older, living in a care home, with frailty, multimorbidity or impaired capacity to consent are under-represented in research, limiting its generalisability. We aimed to evaluate more inclusive recruitment strategies. METHODS: From one UK centre, we invited people with parkinsonism to participate in a cross-sectional study. Postal invitations were followed by telephone reminders and additional support to facilitate participation. Personal consultees provided information on the views regarding research participation of adults with impaired capacity. These approaches were evaluated: (i) using external data from the Parkinson's Real World Impact assesSMent (PRISM) study and Clinical Practice Research Datalink (CPRD), a sample of all cases in UK primary care, and (ii) comparing those recruited with or without intensive engagement. RESULTS: We approached 1,032 eligible patients, of whom 542 (53%) consented and 477 (46%) returned questionnaires. The gender ratio in PRIME-UK (65% male) closely matched CPRD (61% male), unlike in the PRISM sample (46%). Mean age of PRIME participants was 75.9 (SD 8.5) years, compared to 75.3 (9.5) and 65.4 (8.9) years for CPRD and PRISM, respectively. More intensive engagement enhanced recruitment of women (13.3%; 95% CI 3.8, 22.9%; P = 0.005), care home residents (6.2%; 1.1, 11.2%; P = 0.004), patients diagnosed with atypical parkinsonism (13.7%; 5.4, 19.9%; P < 0.001), and those with a higher frailty score (mean score 0.2, 0.1, 0.2; P < 0.001). CONCLUSIONS: These recruitment strategies resulted in a less biased and more representative sample, with greater inclusion of older people with more complex parkinsonism.

Patient and public involvement in the development of health services: Engagement of underserved populations in a quality improvement programme for inflammatory bowel disease using a community-based participatory approach.

INTRODUCTION: Involving people with lived experience is fundamental to healthcare development and delivery. This is especially true for inflammatory bowel disease (IBD) services, where holistic and personalised models of care are becoming increasingly important. There is, however, a significant lack of representation of underserved and diverse groups in IBD research, and there are significant barriers to healthcare access and utilisation among minority groups in IBD. IBD centres need to be aware of these experiences to address barriers via service changes, improve interactions with local communities and promote meaningful engagement for improved health outcomes. METHODS: A pragmatic community-based approach was taken to engage with leaders and members of underserved groups across 11 workshops representing Roma, Afro-Caribbean, people of African descent and the wider black, Asian and minority ethnic (BAME) communities, Muslim women, refugee community members, deprived areas of South Yorkshire, LGBTQ+ and deaf populations. Thematic analysis of field notes identified patterns of attention across the community groups and where improvements to services were most frequently suggested. RESULTS: Findings demonstrated several barriers experienced to healthcare access and utilisation, including language accessibility, staff attitudes and awareness, mental health and stigma, continuity of support, and practical factors such as ease of service use and safe spaces. These barriers acted as a lever to co-producing service changes that are responsive to the health and social care needs of these groups. CONCLUSIONS: Engaging with people from a range of communities is imperative for ensuring that service improvements in IBD are accessible and representative of individual needs and values. PATIENT OR PUBLIC CONTRIBUTION: Local community leaders and members of community groups actively participated in the co-design and development of improvements to the IBD service for a local hospital. Their contributions further informed a pilot process for quality improvement programmes in IBD centres.

Priority populations' experiences of the accessibility and inclusion of recreation centres: a qualitative study.

BACKGROUND: Although the health benefits of physical activity are well documented, certain priority populations are often disproportionately insufficiently active and at higher risk of poor health. Recreation centres have the potential to provide accessible and supportive environments for physical activity for all. However, little is known about priority populations' experiences of these venues and their views of how accessibility and inclusion can be optimised. This study aimed to gain in-depth insights of recreation centre experiences and potential strategies for improving inclusion and accessibility amongst priority populations (women, older adults, ethnic minorities, persons living with disabilities/additional needs, individuals identifying as LGBTQIA+, low socio-economic position). METHODS: This qualitative study (2021-2022) involved 18 semi-structured individual interviews with adult priority population users of recreation centres (50% 65 + years, 61.2% female) in one Melbourne municipality. Participants were asked to discuss their positive and negative experiences at the centres and to identify strategies for enhancing accessibility and inclusion. Interviews were audio-recorded and transcribed verbatim. Content analysis was performed for data analysis. RESULTS: While many participants had positive views of the facilities and programs at the centres, as they met their needs, they also had suggestions for improving accessibility and inclusion. Similarly, most participants were happy with the communications, felt included, and perceived the culture positively. Those who did not feel included at the centres offered many potential strategies for changing the culture, modifying communications (e.g., signage), and establishing partnerships for better access and inclusion. CONCLUSIONS: The present study adds to essential knowledge concerning priority populations' experiences of recreation centres. For recreation facilities that were generally perceived as having positive inclusion and accessibility, the findings nonetheless highlighted suggestions for further enhancement. These strategies may be useful more broadly for improving accessibility and inclusion, thereby promoting physical activity and ultimately health for all.

Care-seeking strategies of migrants during the transition from a specific primary healthcare facility for uncovered individuals to common ambulatory general practice: A French qualitative study.

BACKGROUND: Migrants have complex health needs but face multiple barriers to accessing health care. In France, permanent healthcare access offices (PASSs), as specific primary health care facilities (SPHCs), provide care to people without health insurance coverage. Once these patients obtain health insurance, they are referred to common ambulatory general practice. The aim of this study was to explore migrants' experiences and strategies for seeking common primary care after having been treated by an SPHC. METHODS: We conducted a qualitative study based on grounded theory between January and April 2022. We held semi-structured interviews with migrants who had consulted a PASS. Two researchers performed an inductive analysis. RESULTS: We interviewed 12 migrants aged 22 to 65 to confirm data saturation. The interviewees relied on "referents": professional referents (to be properly treated for specific health problems), guides (to find their way through the healthcare system), or practical referents (to address practical issues such as translation, travel needs, or medical matters). Those who considered the PASS to be a referent expressed disappointment and incomprehension at the time of discharge. Referral procedures and the first encounter with common ambulatory general practice were decisive in whether the interviewees accessed and stayed in a coordinated primary care pathway. The perceived quality of care depended on a feeling of being considered and listened to. For interviewees who received first-time services from an ambulatory general practice, the way in which they were referred to and their first experience with an ambulatory GP could influence their adherence to care. CONCLUSIONS: The conditions of transition from SPHCs to common ambulatory general practice can impact migrants' adherence to a coordinated primary care pathway. Referral can improve these patients' care pathways and ease the transition from a PASS to ambulatory care. Healthcare professionals at SPHCs should pay special attention to vulnerable migrants without previous experience in ambulatory general practice and who depend on referents in their care pathways. For these patients, adapted referral protocols with further individual support and empowerment should be considered.

Beyond individual factors: a critical ethnographic account of urban residential fire risks, experiences, and responses in single-room occupancy (SRO) housing.

BACKGROUND: Burn injuries are a significant public health concern, closely linked to housing conditions and socioeconomic status. Residents in socioeconomically deprived neighbourhoods are at increased risk of exposure to hazards due to older and poorer housing conditions and limited access to fire protection measures. Individual behaviours such as substance use, smoking, and hoarding are often highlighted as primary causes of residential fires, overshadowing the broader socioeconomic and structural factors that also play a significant role in housing safety. This paper explores the correlation between inadequate housing conditions and heightened fire risks leading to burn injuries, focusing on the contextual factors shaping everyday urban fire risks, experiences, and responses of residents living in Single-Room Occupancy (SRO) housing in Vancouver's Downtown East Side (DTES) and staff working in the fire, health, housing (social and private), and non-profit sectors. METHODS: As part of an ongoing ethnographic study, we partnered with the Vancouver Fire Rescue Services (VFRS) to conduct participant observations in private, non-profit, and government-owned SROs, modular homes, and a temporary shelter. This paper synthesizes insights from participant observations from the first author's self-reflexive journals, including informal conversations with approximately fifty-nine individuals such as SRO tenants, SRO managers/caretakers, health workers, burn survivors, municipal staff, not-for-profit staff, and firefighters. RESULTS: Urgent housing-related issues contributing to inequitable everyday urban fire risks were identified, such as structural deficiencies in SRO buildings and systems, inadequate waste management and storage, and inequitable approaches to addressing hoarding. Additionally, disparities in access to information and the interaction between interpersonal and structural stigmas were significant factors, underscoring the pressing need for intervention. CONCLUSION: Communities like DTES, facing precarious housing conditions, disadvantaged neighbourhoods, and complex health and social challenges, necessitate a comprehensive and holistic approach to fire prevention and safety. Recognizing the interplay between housing instability, mental and physical health issues, unregulated toxic drug supply, drug criminalization, and structural inequities allows practitioners from various sectors to develop contextually driven fire prevention strategies. This multifaceted approach transcends individual-level behaviour change and is crucial for addressing the complex issues contributing to fire risks in underserved communities.

High prevalence of zero-dose children in underserved and special setting populations in Ethiopia using a generalize estimating equation and concentration index analysis.

BACKGROUND: Globally, according to the World Health Organization (WHO) 2023 report, more than 14.3 million children in low- and middle-income countries, primarily in Africa and South-East Asia, are not receiving any vaccinations. Ethiopia is one of the top ten countries contributing to the global number of zero-dose children. OBJECTIVE: To estimate the prevalence of zero-dose children and associated factors in underserved populations of Ethiopia. METHODS: A cross-sectional vaccine coverage survey was conducted in June 2022. The study participants were mothers of children aged 12-35 months. Data were collected using the CommCare application system and later analysed using Stata version 17. Vaccination coverage was estimated using a weighted analysis approach. A generalized estimating equation model was fitted to determine the predictors of zero-dose children. An adjusted odds ratio (AOR) with 95% confidence interval (CI) and a p-value of 0.05 or less was considered statistically significant. RESULTS: The overall prevalence of zero-dose children in the study settings was 33.7% (95% CI: 34.9%, 75.7%). Developing and pastoralist regions, internally displaced peoples, newly formed regions, and conflict-affected areas had the highest prevalence of zero-dose children. Wealth index (poorest [AOR = 2.78; 95% CI: 1.70, 4.53], poorer [AOR = 1.96; 95% CI: 1.02, 3.77]), single marital status [AOR = 2.4; 95% CI: 1.7, 3.3], and maternal age (15-24 years) [AOR = 1.2; 95% CI: 1.1, 1.3] were identified as key determinant factors of zero-dose children in the study settings. Additional factors included fewer than four Antenatal care visits (ANC) [AOR = 1.3; 95% CI: 1.2, 1.4], not receiving Postnatal Care (PNC) services [AOR = 2.1; 95% CI: 1.5, 3.0], unavailability of health facilities within the village [AOR = 3.7; 95% CI: 2.6, 5.4], women-headed household [AOR = 1.3; 95% CI:1.02, 1.7], low gender empowerment [AOR = 1.6; 95% CI: 1.3, 2.1], and medium gender empowerment [AOR = 1.7; 95% CI: 1.2, 2.5]. CONCLUSION: In the study settings, the prevalence of zero-dose children is very high. Poor economic status, disempowerment of women, being unmarried, young maternal age, and underutilizing antenatal or post-natal services are the important predictors. Therefore, it is recommended to target tailored integrated and context-specific service delivery approach. Moreover, extend immunization sessions opening hours during the evening/weekend in the city administrations to meet parents' needs.

Facilitators and barriers to accessing hepatitis B care in the postpartum period among foreign-born New Yorkers: a qualitative analysis of case notes.

BACKGROUND: Approximately 241,000 people are living with hepatitis B in New York City. Among those living with hepatitis B, pregnant people are particularly at risk for elevated viral load due to changes in immune response and require prompt linkage to health care. The New York City Department of Health and Mental Hygiene's Viral Hepatitis Program implemented a telephone-based patient navigation intervention for people living with hepatitis B in the postpartum period to connect them with hepatitis B care. METHODS: During the intervention, patient navigators called participants to inquire about their past experience with receiving care, available supports, and barriers to care, and worked with them to develop a plan with participants for linkage to hepatitis B care. The information collected during initial assessments and follow-up interactions were recorded as case notes. In this qualitative study, researchers conducted a thematic analysis of 102 sets of case notes to examine facilitators and barriers to accessing hepatitis B care among the intervention participants, all of whom were foreign-born and interested in receiving hepatitis B patient navigation services. RESULTS: The qualitative analysis illustrated the various ways in which patient navigators supported access to hepatitis B care. Findings suggest that receiving care through a preferred provider was a central factor in accessing care, even in the presence of significant barriers such as loss of health insurance and lack of childcare during appointments. Expectations among family members about hepatitis B screening, vaccination and routine clinical follow up were also identified as a facilitator that contributed to participants' own care. CONCLUSIONS: This study suggests that while there are numerous barriers at the personal and systemic levels, this patient navigation intervention along with the identified facilitators supported people in accessing hepatitis B care. Other patient navigation initiatives can incorporate the lessons from this analysis to support people in connecting to a preferred provider.